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Mechanical Support for Acute Cardiogenic Shock Mark J. Russo, MD, MS Assistant Professor of Surgery Section of Cardiac and Thoracic Surgery University.

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Presentation on theme: "Mechanical Support for Acute Cardiogenic Shock Mark J. Russo, MD, MS Assistant Professor of Surgery Section of Cardiac and Thoracic Surgery University."— Presentation transcript:

1 Mechanical Support for Acute Cardiogenic Shock Mark J. Russo, MD, MS Assistant Professor of Surgery Section of Cardiac and Thoracic Surgery University of Chicago

2 Disclosures No relevant disclosures

3 Severe Acute Cardiogenic Shock Associated w excessive mortality If untreated will lead to imminent death Etiology: Post-cardiotomy, AMI, Myocarditis, Acute on chronic cardiomyopathy, Malignant arrhythmia Goals: Must rapidly stabilize and rest heart Treatment: Mechanical support + OMM Endpoint: Recovery Definitive surgical therapy should not be offered in the acute setting

4 When and How to Initiate MCS

5 Simple Rules for Initiating MCS Pt continues to deteriorate despite increasing drugs Initiate before the patient absolutely needs it If you put an unsalvageable patient on MCS, they remain unsalvageable Its not the devices that are bad, its the patients who are sick

6 Hard Parameters for Initiating MCS Already on inotropes and IABP Increasing support level required Hemodynamics – must maintain – CI >2.0 – BP mean >60mmHg – SBP> 85 mmg – CVP <15 – PCWP <20 – End organ function : renal, hepatic, pulmonary, cerebral Balance – Hemodynamics not attainable – Increasing inotrope requirements especially vasoconstrictors

7 MCS Options Partial Circulatory Support Full Circulatory Support Full Cardiopulmonary Support

8 Partial Circulatory Support IABP Impella/Abiomed Subclavain-IABP

9 Impella Abiomed Micro rotary pump – 2.5 Cath lab, percutaneous insertion – 5.0 (larger, more flow) Graft or cutdown Advantages – Easy to insert – Active de-compression of LV – Less invasive Less support than rotary pumps

10 Impella Abiomed

11 Subclavian Intra-Aortic Balloon Intra-aortic balloon pumps (IABPs) are traditionally inserted through the femoral artery, limiting the patients mobility. Advantages of SC: PVD less of an issue, minimally invasive support, ambulatory Limitations: Time (40-1 hr), peri-stable, Connective tissue disease

12 Subclavian Intra-Aortic Balloon The graft is then tunneled into the pocket. The guidewire is though the skin and then into the graft and then through the subclavian artery into the aorta. Under fluoroscopic guidance, the balloon wire is positioned in the descending thoracic aorta. The balloon is inserted and screened into an appropriate position. The wound over the Gore-Tex graft is closed in layers.

13 Operative Approach

14 Ambulating with IABP

15 Introduction Methods Results Conclusions Mean duration of support : 21 days (range: 3 – 90) 19 patients (95%) were successfully bridged to transplant or LVAD. 2 patients (10%) required an emergent LVAD for worsening heart failure. All patients were extubated and ambulatory within 24 hours following the procedure No device-related complications while on support 1 device exchanged at bedside Outcomes (n=20)

16 Full Circulatory Support Extracorporeal VADs – LVADs – RVADs – BIVADs Implantable VADs – are not for acutely decompensating patients – Surgical trauma – Bridge to ?

17 Management options – what to support? LVAD – ECHO (function and MR) – High filling pressures with hypotension and low CO – PCWP >18 with mean BP <70mmHg and CI<1.8 RVAD – ECHO (function and TR) – CVP > 15mmHg with mPA < 1.5 x CVP – Underfilled LV – mPA > 2x CVP relative exclusion (may need LVAD or ECMO)

18 Centrimag Indications: Short-term support (<15 days) Bridge-to-decision (recovery vs definitive therapy) Device: a single-use centrifugal pump, a motor, and a primary drive console. the motor magnetically levitates the impeller, achieving rotation with no friction or wear rotates at rpm Flows: up to 9.9L/min

19 LVAD cannulation Surgical – Outflow from device Aorta, femoral artery – Inflow to device LA/PV LV

20 Centrimag Off Pump Sternotomy Left Thoractomy

21 RVAD cannulation Surgical – Outflow from device PA - Do not push in too far RVOT across PV – Inflow to device RA – careful positioning RV Percutaneous – Outflow from device Via long cannula to PA – Inflow to device Femoral vein, IJ, subclavian

22 Advantages of Centrimag Relatively inexpensive Reliable High level of support Allows for further esculation of care – Implantable device – RVAD – ECMO

23 Case 65 year old male S/P traumatic right BKA after MVA Fully functional, employed as businessman Crescendo chest pain for 2 weeks, neglected Unrelenting angina for 24 hours before presenting to ER LHC performed

24 Coronary angiogram

25 Patient course Emergency IABP placed Transferred to tertiary care center Hemodynamic data – BP 70/50 augmented – PA 45/27 – CVP 16 – CI 1.2 Labs: Cr 2.5; TB 4.0; AST/ALT >1,000 Support: IABP, dopamine 20 g/kg/min, dobutamine 20 g/kg/min, ventilator with paO 2 70 on FIO 2 80%

26 Patient course Anuric Peripherally cold Obtunded ECHO: – No AI – Severe MR – Moderate TR – LVEF <10%, without thrombus

27 Hospital course Centri-Mag LVAD placed off pump. Reversed acidosis Recovered renal and hepatic function Pulmonary edema resolved Total CT output <300cc Anticoagulation started POD#1 Extubated POD#3 HeartMate II placed POD#5 to allow for rehabilitation

28 Full Cardiopulmonary Support Heart and pulmonary failure ECMO – Standard (Thoratec Centri-mag/Maquet Quadrox) – Portable (Maquet Cardiohelp)

29 Criteria With optimized ventilator settings – pO2 < 65mmHg – Sa02 < 90% – PEEP > 10

30 Standard ECMO: Centrimag + Quadrox Centrimag Quadrox

31 In Situ Centrimag Quadrox

32 Advantages of Centrimag/Quadrox High level of support Reliable Relatively Inexpensive Peripheral/Percutaneous/Central Access Oxygenator can be cut-in to BIVAD/RVAD circuit at the bedside

33 Disadvantages of ECMO It does not decompress the heart – unless LV vent placed Contraindicated in moderate to severe AI Oxygenator induced inflammatory response Need for anticoagulation – ACT


35 Acute Respiratory Distress Syndrome (ARDS) Septic Shock Syndrome Multiple Organ System Failure Pulmonary Embolism CRITICAL CARE MEDICINE POSSIBLE APPLICATIONS

36 CARDIOHELP All in one heart-lung support system 10 kg (22lbs) 14 x 10 x 17 inches Optional Sprinter Cart for in hospital mobility

37 General Surgery Neurosurgery Cardiac Surgery Vascular Surgery Operating Room: Cardiac Care Neonatal Intensive Care Critical Care Unit: Options Patient Transport: Interventional Cardiology Procedures Hybrid OR / Cath Lab:

38 TRANSFER OPTIONS Transfer pt and initiate at accepting center Transferring center initiates ECMO – Convert to Cardiohelp Accepting initiates ECMO on site using Cardiohelp In cardiovascular disease, we have a just say YES policy

39 Case 54yo M p/w CP to outside ED Troponin 20 Taken to cath lab – Found to have RCA occlusion – Intervention unsuccessful – Worsening stability c high dose pressors – Intubated/IABP placed Transferred to UofC

40 Case Airlifted to UofC Directly to the OR Peripherally cool, MAPs 55, anuric, SaO2 85% Lactate: 7, pH 7.21, pO2 57 ECHO: severe RV failure, LVEF=35%

41 Case Peripheral cannulation via femoral cutdown – RFA – arterial inflow – RFV – venous drainage – Antegrade to RFA via 12Fr cannula

42 Case OR – Flow: 6.0L, FiO2=100% – MAPs 70s, SaO2=100% HD#1 – Weaning pressors – CVVHD – pH normalized, PaO2=300s HD#4 – Off pressors and inotropy

43 Case HD#6 – Weaned from ECMO after 2 day wean Wean flows – IABP, inotropy HD#10 – Extubated HD#12 – Off inotropy HD#19 – Discharged to rehab

44 Support initiated – then what? Maintenance: – Anticoagulation Initial – ECMO ACT 150 – 180, VAD none After bleeding stops – 150 – 180 sec – Minimize inotropic support – Evaluate cerebral and other end organ function – IABP for some pulsatility End goals: – Recovery and wean – Bridge to longer term solution Definitive surgical treatment is not appropriate in acute setting

45 Weaning / recovery Native ejections with decreasing support Allow time to re-equilibrate Continuous SG useful for LVAD (even for RVAD as it give MVO2 saturation) ECHO Minimize anesthesia Bad sign if escalating inotropes or requiring IABP

46 Outcomes Difficult to characterize given heterogeneity of patients Recovery depends on ability to repair myocardium Bridge to device depends on: – Earlier initiation of mechanical therapy – Single vs bi-VAD support – Liver function marker for survival – Respiratory status – Neuro Reports vary from 30 – 80% success rates

47 Summary Paradigm shift – Initiate earlier – Better less inflammatory technology – Easier to initiate – Better Outcomes

48 Take Home Points MCS should be initiated early Temporary support, not implantable device Definitive therapy should only be offered after patient demonstrates measurable recovery

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